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PROGRAM STUDI PENDIDIKAN NERS

STIKes PATRIA HUSADA BLITAR

ASUHAN KEPERAWATAN KELUARGA

Hari :
Tanggal :
Jam :

1. DATA UMUM
a. Nama Kepala Keluarga : .
b. Umur KK : .
c. Alamat dan telepon : .
d. Pekerjaan KK : .
e. Pendidikan KK : .
f. Agama KK : .
g. Suku bangsa KK : .
h. Komposisi keluarga : .
No. Nama Jenis Hub. dg Umur Pendidikan Agama Pekerjaan
Kelamin KK
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2.
3.
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5.
6.
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10.
i. Genogram
PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

j. Tipe Keluarga
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k. Suku Bangsa
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l. Agama
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m. Status sosial ekonomi keluarga
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n. Aktivitas rekreasi keluarga
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2. RIWAYAT TAHAP PERKEMBANGAN KELUARGA


a. Tahap perkembangan keluarga saat ini
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b. Tahap perkembangan keluarga yang belum terpenuhi
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c. Riwayat kesehatan keluarga inti
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d. Riwayat kesehatan keluarga sebelumnya
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3. LINGKUNGAN
a. Karakteristik rumah
Denah rumah
PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

b. Keadaan lingkungan dalam rumah


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c. Keadaan lingkungan di luar rumah
Pemanfaatan halaman
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Sumber air minum
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Pembuangan air kotor
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Pembuangan sampah
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Jamban
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Sumber pencemaran
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Sanitasi rumah
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d. Karakteristik tetangga dan komunitas
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e. Mobilitas geografi keluarga
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f. Perkumpulan keluarga dan interaksi dengan masyarakat
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g. Sistem pendukung keluarga dan ecomap
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4. STRUKTUR KELUARGA
a. Pola komunikasi
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PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

b. Struktur kekuatan atau kekuasaan keluarga


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c. Struktur peran (formal dan informal)
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d. Nilai dan norma
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5. FUNGSI KELUARGA
a. Fungsi afeksi
Kebutuhankebutuhan keluarga, polapola respon
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Hubungan keakraban
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Pertalian hubungan (diagram kedekatan dalam keluarga)


Perpisahan dan kekerabatan
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b. Fungsi sosial
Cara pola asuh pada anak
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Siapa yang menjadi pelaku sosialisasi anakanak
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Nilai anakanak dalam keluarga
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Keyakinan budaya yang mempengaruhi pola asuh
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PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

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Pengaruh kelas sosial dalam pengasuhan
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Estimasi resiko masalah pengasuhan
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Kelayakan lingkungan rumah untuk bermain bagi anak
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c. Fungsi perawatan kesehatan
Keadaan kesehatan
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Kebersihan perorangan
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Penyakit yang sering diderita
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Penyakit keturunan
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Penyakit kronis atau menular
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Kecacatan
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Pola makan
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Pola istirahat
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Ketergantungan obat atau bahan
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Mencari pelayanan kesehatan
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d. Fungsi reproduksi
PROGRAM STUDI PENDIDIKAN NERS
STIKes PATRIA HUSADA BLITAR

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6. STRESS DAN KOPING KELUARGA


a. Stressor jangka pendek dan jangka panjang
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b. Kemampuan berespon terhadap stressor
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c. Strategi koping yang digunakan
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d. Strategi adaptasi disfungsional
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7. PEMERIKSAAN FISIK
Hari :
Tanggal :
TB BB LILA TD N R S
No Nama Keterangan keluhan
Cm Kg Cm Mm/Hg x/ x/ C
1.
2.
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8. HARAPAN KELUARGA TERHADAP PERAWATAN KESEHATAN KELUARGA


a. Persepsi terhadap masalah
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b. Harapan terhadap masalah
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Perawat yang mengkaji,